Tag Archives: chronic illness

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Conserving energy

I was out of clinic for two years and then very part time for a year and now not quite full time as a temp. I bargained to not quite be full time.

The electronic medical record is having a consequence, along with the pressure to see more people faster. The primary care doctors, at least the younger ones, do not seem to call their peer specialists any more. (Family Medicine is a specialty, just as Internal Medicine and Obstetrics/Gynecology are.) I called a gastroenterologist and left a message last week about a difficult and complex patient. The patient had cried three times during our visit. The gastroenterologist was very pleased I had called, was helpful, agreed with my plan of using the side effects of an antidepressant to try to help our patient, and thanked me three times for calling her. Wow. I am used to calling because during my first decade in Washington State, our rural hospital had Family Practice, General Surgery, a Urologist, Orthopedics and a Neurologist. For anything else, we called. I knew specialists on the phone for a one hundred mile radius and some knew me well enough that they’d say a cheery hi.

Now communication is by electronic medical record and email on the medical record and by (HORRORS) TEXT. Ugh. I think that there is quite a lot of handing the patient off by referring them to the Rheumatologist or Cardiologist or whatever, but the local Rheumatologist is booked out until February for new patients. That leaves the patient in a sort of despair if we don’t keep checking in on the problem. If I am worried, I call the Rheumatologist and say, “What can I do now?” I’ve had two people dropping into kidney failure and both times a call to the Nephrologist was very very helpful. I ordered the next tests that they wanted and got things rolling. One patient just got the renal ultrasound about three months after it was ordered. Sigh.

I have one patient who is booked in February for a specialist. I called that specialist too, they did not want any further tests. I told the patient, “You aren’t that sick so you won’t be seen for a while. It isn’t first come first serve: it is sickest first. We all have to save room for the emergencies and sometimes those are overwhelming.” The specialist agreed and the patient is fine with that and I think pleased to know that we do not think she’s that sick. She feels better. If things get worse, she is to come see me and might get moved up. Neither I nor the specialist think that will happen.

Is this conservation of energy, to communicate by email and text? I don’t think so. I think sometimes a phone call is much more helpful, because the other physician knows exactly what I am worrying about and they can tell me their thoughts swiftly. Sometimes they want me to start or change a medicine. Things can get lost in the overwhelming piles of data and the emails and labs and xrays and specialist notes all flowing in.

My Uncle Jim (known as AHU for Ancient Honorable Uncle Jim) used to sing part of this:

Yeah, that’s just how I call my fellow specialists.

For the Ragtag Daily Prompt: conservation. Don’t cats win at conservation of energy?

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Covid-19 and walking pneumonia

I wrote this essay in July 2017. Before Covid-19. It is clear that Covid-19 is also causing a walking pneumonia. People are exhausted when they get out of bed. No fever, they may not cough much, but if they get up, they can feel exhausted. The key to this is the heart rate, the pulse. If the pulse jumps 30 points faster or more, this implies lung swelling and reduced lung capacity. Right now, the only treatment we have is rest and time to heal. I should know, I’ve had really bad walking pneumonia four times: the first two times I was out for two months. The third time 6 months with 6 more months half days and chronic fatigue. The fourth time put me on oxygen.

I want to offer hope to the people with Long Covid-19. Having been through four bad pneumonias, with increasingly long recovery times, and now disabled for doing Family Medicine, I have experience to share. I will write more about that in the next essay.

From 2017: Walking pneumonia is changing.

The classic bugs are four “atypical bacteria”:

mycoplasma pneumonia
chlamydia pneumonia (this is not the STD chlamydia. Different one.)
legionella
pertussis (whooping cough)

However, streptococcus pneumonia can also be a walking pneumonia OR a lobar pneumonia. In a lobar pneumonia the person usually is short of breath, running a fever of 102-104, and they point to where it is: hurts in the right upper chest. On chest x-ray there will be consolidation: whited out from fluid or swelling instead of nice ribs and dark air. They are often tachycardic and hypoxic.

In walking pneumonia the person often has no or minimal fever, they just feel tired or short of breath when they do things, and the chest xray can be “clear”. It isn’t really “normal”, it’s just that the bacteria or virus affects the entire lungs and causes some swelling throughout and doesn’t white it out.

“Double” pneumonia is when the chest film is whiting out on both sides. We also see the lungs whiting out with ARDS — acute respiratory distress syndrome. So after trauma in a car wreck and lots of broken ribs, the lungs can be bruised too and white out. Ow. Influenza virus can cause lung swelling and in the 1917-1918 flu infected military recruits lungs were swelling shut. They would turn blue and die.

“My” strep that I’ve had pneumonia with twice is streptococcus A, not strep pneumonia. It causes strep throat mostly though it can invade and cause sepsis or pneumonia or cellulitis. There are currently 4000+ known strains of strep A, and some are resistant to antibiotics or can cause kidney damage or do all sorts of nasty things. I think that “my” strep is resistant to azithromycin.

The current guidelines say to treat walking pneumonia with azithromycin. However, a paper came out this year saying that resistance to azithromycin is rising among streptococcus pneumonia and that nearly 50% of strains tested were resistant. Uh-oh. That means that azithomycin doesn’t work and the person can get sicker and may die. I talked to a pulmonologist in Seattle when I needed help with someone. He said that he would have said there weren’t any resistant strep pneumo strains here in Washington except that he had one intubated and in the ICU right then. “I’m convinced now, ” he said.

A lobar pneumonia is easier to diagnose. Abnormal chest x-ray, reasonably healthy people run a high white blood cell count (so my frail folks, immunosupressed folks and 90 year olds don’t raise their white blood cell count), and a fever (ditto) and look sick. The walking pneumonia people come in saying they have been coughing for 3 weeks or 4 weeks or two months. I am doing more lab testing because of the resistance.

This winter I have seen 6 different causes of walking pneumonia here: influenza A, respiratory syncytial virus (In more than one person over 60. That is NOT who the books say it should affect. It’s supposed to mostly cause bronchiolitis in babies and preemies), pertussis, strep pneumococcus, strep A and none of the above. All looking pretty much the same, but with different treatment.

https://wwwnc.cdc.gov/eid/article/15/8/08-1187_article
https://www.cdc.gov/pneumonia/atypical/mycoplasma/index.html
http://www.medscape.com/viewarticle/820736
https://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=79
RSV: http://kidshealth.org/en/parents/rsv.html
Mycoplasma resistance to azithromycin has been reported too: http://erj.ersjournals.com/content/36/4/969

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what would YOU choose?

Here is a story of a choice about an abortion, a theraputic abortion, where a mother has to make a difficult choice. I have seen Family Medicine patients since 1991, so this will not identify a particular person. No HIPAA problem.

I see a new patient in clinic, a woman, who already has children. She has back pain. All is routine until she says, “Sometimes my leg goes numb from the knee down.” I stop. This is NOT normal. “Completely numb?” I say. “Not patchy?” “Yes.” “How often?” I ask. She shrugs. “Not very.” “If it happens again, call me and I want to see you right away.”

Why? This is unusual because most numbness follows dermatomes if it is from back pain. The dermatomes on the skin wrap from the back down the leg all the way to the toes. When someone describes numbness or the pain of shingles in that distribution, we know which nerve is affected. Numbness from the knee down can come from diabetes and other causes, but it is not on one side and it doesn’t come and go. So the unusual stands out for me.

“Anything else weird?”

“I had vision problems in my last pregnancy. They sent me to specialists, even a neuro opthamologist. He couldn’t find anything.”

“Ok.” I shrug. We move on.

She calls two days later. “Both legs are numb from the knee down.”

“Come in today,” I say.

Both legs ARE numb from the knee down. She also can’t lift her feet. The muscles from the knees down are weak. I get neurology on the phone. “MRI her from the top of her head to the base of her spine.” I call the hospital and set it up. That day.

She has seven brain lesions suspicious for multiple sclerosis. She did have an MRI in the previous pregnancy, which was negative. I do not remember how old the child was, 2-4 years or more when I saw mother.

I call her back in for results, we talk about specialists, and I call a neurologist in the nearest big city, three hours by car from where she lives. We start medications and my patient is scheduled.

She has multiple sclerosis. The flare improves. The visual symptoms were MS in the previous pregnancy, but it was not yet visible on brain MRI.

Then she gets pregnant again. Her symptoms immediately flare. She comes to me and I call the neurologist.

The symptoms are not a little worse. Much worse. “I suggest she terminate the pregnancy.”

My patient is horrified. Until the neurologist’s next words. “She needs to terminate if she wants to be able to walk for the children she has.”

My patient chooses an abortion, to terminate the pregnancy. Because she has a bad version of MS*, she remembers the symptoms in the last pregnancy, she is young, she is clearly progressing and she wants to take care of the children she already has.

What would YOU choose? For yourself, for your sister, for your wife. If you are male, do you have any right to make that choice? Now picture yourself pregnant with that choice. And thank you for reading this.

*Addendum: present evidence says that multiple sclerosis does NOT worsen with pregnancy. However, another illness, NMO (neuromyelitis optica) instead tends to become more active in pregnancy. It previously was lumped in with MS until the antibodies (anti-NMO) were identified and it was realized it’s a different subtype of demyelination disease, with its own treatment options. Medicine changes over time and the woman, the neurologist and I were working with the information available at that time.

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Dinosaurs got colds too

https://www.abc.net.au/news/science/2022-02-11/dolly-diplodocid-dinosaur-pneumonia-disease-respiratory-illness/100817258

Dolly the Dinosaur shows evidence of a respiratory infection: aka a “cold”. And a chronic cold. She died at age 15, about half way through her lifespan. I suspect a little guesswork there. Do old dinosaurs turn grey?

There are dinosaur bone changes in Dolly from chronic infection. The scientist posted photographs on the internet and other bone experts said, that is infection. That is evidence of respiratory infection. “A lot of the times when any disease or trauma is found in a dinosaur skeleton, it’s often in limb bones where you expect it to happen,” Dr Poropat said. “Seeing it where the air sacs penetrate the vertebrae in a sauropod is quite unusual.” Also, she didn’t die of volcanic ash: “Inhalation of volcanic ash can cause a disease similar to mesothelioma.” Who knew? I haven’t kept up on my dinosaur medicine. The pattern of lesions also didn’t fit with lung cancer. Instead, Dr Woodruff and his colleagues think bacterial or fungal infections such as chlamydiosis and aspergillosis are prime suspects. These respiratory infections are common in birds today. “We don’t know for sure if the infection was bad enough to ultimately do Dolly in.”

Dolly, with her long neck, had neck arthritis from a chronic cold. She thought it was allergies.

Coronoviruses are colds. We are have a pandemic of a really really nasty killer cold and a cold that is doing long term damage in way too many people. That seems hugely ironic to me. I thought it would be influenza. After flu nearly killed me in 2003 I read about it and have enormous respect for it. And influenza is endemic and is always circling the world, in the colder regions.

My ideas about allergies and asthma are changing. We define asthma by whether people respond to albuterol. I do not respond to albuterol so I do not have asthma. However, I respond to other adrenaline like molecules: coffee caffeine and terbutaline. So do I have an asthma like illness? My allergy testing in 2014 was resoundingly negative. I tested for celiac in 2020, because I just did not feel well. Negative. I have not retested yet, but even if that antibody testing is negative, it was gluten that flared up diverticulitis in me. The thing is, there could be other antibodies. Loads of them. We all make different ones.

I am thinking about tubulin. Tubulin powers our muscles and cilia and flagella. It is mitochondrial. We inherit mitochondria from the mother only: it is in the egg but not the sperm. Mitochondria is matrolineal. My son and daughter both have my mitochondria. I have a photograph of my maternal grandmother’s mother. Her expression is amazingly like my daughter’s expression when she is thinking. My daughter has my poor spelling skills, my attitude towards work, and her father’s muscular endurance. During college, her father’s goal was five sports a day. In high school my daughter said that she “just didn’t feel good” when the pool was closed. She was used to swimming 3-5 miles a day and lifting weights. Her father can get on a bicycle and ride at the speed of talking all day. He also has pioneered “jog golfing” in his area. When the golf course is empty in the winter, he plays golf and jogs from one hole to the next with his bag. Yes, he is nuts, I agree. I am jealous of that endurance.

The inheritance of antibodies would be from both parents, because they are made by the white blood cells. Do parents and children make the same antibodies or are they entirely different? I do not know that. I took an immunology course when I worked at NIH in the 1980s. I also had some immunology in medical school, but not nearly to the level that I am interested in now. I think I am hunting for a really good immunology course. And maybe more information about dinosaur medicine.

RDP-SUNDAY-THREAD

For the Ragtag Daily Prompt: thread. This post follows the thread of my thoughts this morning